Techniques for Caesarean Section Cochrane

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Techniques for caesarean section (Review)

Hofmeyr GJ, Mathai M, Shah AN, Novikova N

This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published inThe Cochrane Library 2009, Issue 2

http://www.thecochranelibrary.com

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T A B L E O F C O N T E N T S 1 HEADER . . . . 1 ABSTRACT . . . . 2

PLAIN LANGUAGE SUMMARY . . . .

2 BACKGROUND . . . . 5 OBJECTIVES . . . . 5 METHODS . . . . 7 RESULTS . . . . 22 DISCUSSION . . . . 23 AUTHORS’ CONCLUSIONS . . . . 23 ACKNOWLEDGEMENTS . . . . 24 REFERENCES . . . . 29 CHARACTERISTICS OF STUDIES . . . . 41 DATA AND ANALYSES . . . .

Analysis 1.1. Comparison 1 Joel-Cohen based versus Pfannenstiel (all trials), Outcome 1 Serious complications. . . 44 Analysis 1.2. Comparison 1 Joel-Cohen based versus Pfannenstiel (all trials), Outcome 2 Blood loss. . . 46 Analysis 1.3. Comparison 1 Joel-Cohen based versus Pfannenstiel (all trials), Outcome 3 Blood transfusion. . . . 49 Analysis 1.4. Comparison 1 Joel-Cohen based versus Pfannenstiel (all trials), Outcome 4 Operating time (minutes). . 51 Analysis 1.7. Comparison 1 Joel-Cohen based versus Pfannenstiel (all trials), Outcome 7 Postoperative haematocrit level. 53 Analysis 1.8. Comparison 1 Joel-Cohen based versus Pfannenstiel (all trials), Outcome 8 Haemoglobin fall > 4 g%. . 55 Analysis 1.9. Comparison 1 Joel-Cohen based versus Pfannenstiel (all trials), Outcome 9 Wound infection. . . 56 Analysis 1.10. Comparison 1 Joel-Cohen based versus Pfannenstiel (all trials), Outcome 10 Wound haematoma. . . 59 Analysis 1.11. Comparison 1 Joel-Cohen based versus Pfannenstiel (all trials), Outcome 11 Wound breakdown. . . 60 Analysis 1.12. Comparison 1 Joel-Cohen based versus Pfannenstiel (all trials), Outcome 12 Endometritis. . . 62 Analysis 1.13. Comparison 1 Joel-Cohen based versus Pfannenstiel (all trials), Outcome 13 Time to mobilisation (hours). 64 Analysis 1.14. Comparison 1 Joel-Cohen based versus Pfannenstiel (all trials), Outcome 14 Time to oral intake (hours). 66 Analysis 1.15. Comparison 1 Joel-Cohen based versus Pfannenstiel (all trials), Outcome 15 Time to return of bowel

function (hours). . . 68 Analysis 1.16. Comparison 1 Joel-Cohen based versus Pfannenstiel (all trials), Outcome 16 Time to breastfeeding initiation

(hours). . . 70

Analysis 1.17. Comparison 1 Joel-Cohen based versus Pfannenstiel (all trials), Outcome 17 Fever treated with antibiotics or as defined by trial authors. . . 72 Analysis 1.18. Comparison 1 Joel-Cohen based versus Pfannenstiel (all trials), Outcome 18 Repeat operative procedures on

the wound. . . 75

Analysis 1.19. Comparison 1 Joel-Cohen based versus Pfannenstiel (all trials), Outcome 19 Postoperative pain as measured by trial authors. . . 77 Analysis 1.20. Comparison 1 Joel-Cohen based versus Pfannenstiel (all trials), Outcome 20 Number of analgesic

injections. . . 79

Analysis 1.24. Comparison 1 Joel-Cohen based versus Pfannenstiel (all trials), Outcome 24 Time from skin incision to delivery (minutes). . . 81 Analysis 1.28. Comparison 1 Joel-Cohen based versus Pfannenstiel (all trials), Outcome 28 Apgar score < 7 at 5 minutes. 83 Analysis 1.29. Comparison 1 Joel-Cohen based versus Pfannenstiel (all trials), Outcome 29 Neonatal intensive care

admission. . . 85

Analysis 1.37. Comparison 1 Joel-Cohen based versus Pfannenstiel (all trials), Outcome 37 Length of postoperative stay for

mother (days). . . 86

Analysis 4.2. Comparison 4 Joel-Cohen based versus traditional (lower midline incision) (all trials), Outcome 2 Blood

loss. . . 89

Analysis 4.4. Comparison 4 Joel-Cohen based versus traditional (lower midline incision) (all trials), Outcome 4 Operating

time. . . 89

Analysis 4.8. Comparison 4 Joel-Cohen based versus traditional (lower midline incision) (all trials), Outcome 8

Postoperative anaemia. . . 90 i Techniques for caesarean section (Review)

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Analysis 4.9. Comparison 4 Joel-Cohen based versus traditional (lower midline incision) (all trials), Outcome 9 Wound

infection. . . 90

Analysis 4.11. Comparison 4 Joel-Cohen based versus traditional (lower midline incision) (all trials), Outcome 11 Wound

breakdown. . . 91

Analysis 4.12. Comparison 4 Joel-Cohen based versus traditional (lower midline incision) (all trials), Outcome 12

Endometritis. . . 91

Analysis 4.13. Comparison 4 Joel-Cohen based versus traditional (lower midline incision) (all trials), Outcome 13 Time to

mobilistion. . . 92

Analysis 4.17. Comparison 4 Joel-Cohen based versus traditional (lower midline incision) (all trials), Outcome 17 Fever treated with antibiotics or as defined by trialists. . . 92 Analysis 4.37. Comparison 4 Joel-Cohen based versus traditional (lower midline incision) (all trials), Outcome 37 Length

of postoperative hospital stay for mother. . . 93 Analysis 7.2. Comparison 7 Misgav-Ladach versus modified Misgav-Ladach (all trials), Outcome 2 Blood loss. . . 93 Analysis 7.4. Comparison 7 Misgav-Ladach versus modified Misgav-Ladach (all trials), Outcome 4 Operating time. . 94 Analysis 7.14. Comparison 7 Misgav-Ladach versus modified Misgav-Ladach (all trials), Outcome 14 Time to oral intake. 94 Analysis 7.15. Comparison 7 Misgav-Ladach versus modified Misgav-Ladach (all trials), Outcome 15 Time to return of

bowel function. . . 95

Analysis 7.19. Comparison 7 Misgav-Ladach versus modified Misgav-Ladach (all trials), Outcome 19 Postoperative pain as measured by trial authors. . . 95 Analysis 7.24. Comparison 7 Misgav-Ladach versus modified Misgav-Ladach (all trials), Outcome 24 Time from skin

incision to delivery. . . 96 Analysis 7.37. Comparison 7 Misgav-Ladach versus modified Misgav-Ladach (all trials), Outcome 37 Length of

postoperative hospital stay for mother. . . 96 Analysis 10.1. Comparison 10 Extraperitoneal versus intraperitoneal caesarean section, Outcome 1 Serious complications. 97 Analysis 10.5. Comparison 10 Extraperitoneal versus intraperitoneal caesarean section, Outcome 5 Maternal mortality. 97 Analysis 10.17. Comparison 10 Extraperitoneal versus intraperitoneal caesarean section, Outcome 17 Fever treated with

antibiotics or as defined by trialists. . . 98 Analysis 10.18. Comparison 10 Extraperitoneal versus intraperitoneal caesarean section, Outcome 18 Repeat operative

procedures on the wound. . . 98 98 WHAT’S NEW . . . . 99 HISTORY . . . . 99 CONTRIBUTIONS OF AUTHORS . . . . 99 DECLARATIONS OF INTEREST . . . . 99 SOURCES OF SUPPORT . . . . 100 INDEX TERMS . . . . ii Techniques for caesarean section (Review)

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[Intervention Review]

Techniques for caesarean section

G Justus Hofmeyr1_{, Matthews Mathai}2_{, Archana N Shah}2_{, Natalia Novikova}3

1_{Department of Obstetrics and Gynaecology, East London Hospital Complex, University of the Witwatersrand, University of Fort} Hare, Eastern Cape Department of Health, East London, South Africa. 2Department of Making Pregnancy Safer, World Health Organization, Geneva, Switzerland.3_{Department of Obstetrics and Gynaecology, East London Hospital Complex, East London, South} Africa

Contact address: G Justus Hofmeyr, Department of Obstetrics and Gynaecology, East London Hospital Complex, University of the Witwatersrand, University of Fort Hare, Eastern Cape Department of Health, Frere and Cecilia Makiwane Hospitals, Private Bag X 9047, East London, Eastern Cape, 5200, South [email protected]. (Editorial group: Cochrane Pregnancy and Childbirth Group.)

Cochrane Database of Systematic Reviews, Issue 2, 2009 (Status in this issue: Unchanged) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. DOI: 10.1002/14651858.CD004662.pub2

This version first published online: 23 January 2008 in Issue 1, 2008.

Last assessed as up-to-date: 5 November 2007. (Help document - Dates and Statusesexplained)

This record should be cited as: Hofmeyr GJ, Mathai M, Shah AN, Novikova N. Techniques for caesarean section.Cochrane Database of Systematic Reviews 2008, Issue 1. Art. No.: CD004662. DOI: 10.1002/14651858.CD004662.pub2.

A B S T R A C T Background

Rates of caesarean section (CS) have been rising globally. It is important to use the most effective and safe technique.

Objectives

To compare the effects of complete methods of caesarean section; and to summarise the findings of reviews of individual aspects of caesarean section technique.

Search strategy

We searched the Cochrane Pregnancy and Childbirth Group’s Trials Register (August 2007), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2007, Issue 3) and reference lists of identified papers.

Selection criteria

Randomised controlled trials of intention to perform caesarean section using different techniques.

Data collection and analysis

Two review authors independently assessed studies and extracted data.

Main results

’Joel-Cohen based’ compared with Pfannenstiel CS was associated with:

less blood loss, (five trials, 481 women; weighted mean difference (WMD) -64.45 ml; 95% confidence interval (CI) -91.34 to -37.56 ml);

shorter operating time (five trials, 581 women; WMD -18.65; 95% CI -24.84 to -12.45 minutes);

postoperatively, reduced time to oral intake (five trials, 481 women; WMD -3.92; 95% CI -7.13 to -0.71 hours);

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less fever (eight trials, 1412 women; relative risk (RR) 0.47; 95% CI 0.28 to 0.81);

shorter duration of postoperative pain (two comparisons from one trial, 172 women; WMD -14.18 hours; 95% CI -18.31 to -10.04 hours);

fewer analgesic injections (two trials, 151 women; WMD -0.92; 95% CI -1.20 to -0.63); and

shorter time from skin incision to birth of the baby (five trials, 575 women; WMD -3.84 minutes; 95% CI -5.41 to -2.27 minutes). Serious complications and blood transfusions were too few for analysis.

Authors’ conclusions

’Joel-Cohen based’ methods have advantages compared to Pfannenstiel and to traditional (lower midline) CS techniques, which could translate to savings for the health system. However, these trials do not provide information on mortality and serious or long-term morbidity such as morbidly adherent placenta and scar rupture.

P L A I N L A N G U A G E S U M M A R Y Techniques for caesarean section

Caesarean sections are performed as both elective and urgent procedures and the rates are rising. The major complications are intraoper-ative damage to organs, anaesthetic complications, bleeding, infection and thromboembolism. The techniques used vary considerably. Available evidence from randomised controlled trials suggests that the Joel-Cohen based techniques (Joel-Cohen, Misgav-Ladach) have short-term advantages over Pfannenstiel (11 trials) and traditional lower midline (two trials) methods. Blood loss, operating time, time from skin incision to birth of the baby, use of pain killers, time to oral intake and bowel function or mobilisation and fever are all reduced.

Use of Joel-Cohen based methods could result in improved short-term outcomes and savings for health systems but robust data on long-term outcomes (pain, fertility, morbidly adherent placenta and rupture of the uterus) after the different techniques (including two suture layers compared with single-layer uterine closure) are needed.

B A C K G R O U N D

Caesarean section is one of the most commonly performed ma-jor abdominal operations in women in both affluent and low-in-come countries. Rates vary considerably between countries and health services (Dumont 2001;Murray 1997;Pai 1999). Global estimates indicate a caesarean section rate of 15% worldwide, ranging from 3.5% in Africa to 29.2% in Latin America and the Caribbean (Betran 2007). Studies from the United States of Amer-ica (Menacker 2001), the United Kingdom (Thomas 2001) and China (Cai 1998) report rates between 20% and 25%. A study in Latin America found a range of 1.6% in a Haitian hospital to 40% in Chile, and above 50% in most private hospitals (Belizan 1999). Rates from West and East African countries ranged from 0.3% in Niger to 10.5% in Kenya (Beukens 2001). Before 1970, caesarean section rates in most middle- to high-income countries ranged between 3% and 5%.

There are many possible ways of performing a caesarean section. A study of obstetricians in the UK found a wide variation in

tech-niques (Tully 2002). For elective surgery more than 80% used the Pfannenstiel abdominal entry and double-layer uterine clo-sure. For emergency surgery, more used the Joel-Cohen abdominal entry. A North American survey of Obstetric and Gynaecologic residents found that 77% use a Pfannenstiel incision for urgent or emergency caesarean sections, 55% use single-layer closure of the uterine incision, 37% use double-layer closure, while 11% use single-layer closure only in women undergoing concomitant ster-ilization (Dandolu 2006). The history of caesarean section tech-niques has been reviewed byLurie 2003. The techniques used may depend on many factors including the clinical situation and the preferences of the operator. Caesarean section is often performed as an emergency procedure after hours when senior staff may not be immediately available. It is important that all those who per-form this operation use the most effective and safe techniques, as determined by a systematic review of randomised trials. Caesarean sections may be elective or emergency procedures (usu-ally during labour). Common reasons for carrying out caesarean 2 Techniques for caesarean section (Review)

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section include:

1. failure to progress in labour;

2. suspected fetal distress (see review ’Operative versus conservative management for ’fetal distress’ in labour’ (Hofmeyr 1998)); 3. previous uterine surgery;

4. very low birthweight (see review ’Elective caesarean section ver-sus expectant management for delivery of the small baby’ (Grant 2001));

5. fetal malpresentation (e.g. breech, transverse lie) (see review ’Planned caesarean section for term breech delivery’ (Hofmeyr 2003));

6. placenta praevia (see review ’Interventions for suspected placenta praevia’ (Neilson 2003a));

7. placental abruption (see review ’Interventions for treating pla-cental abruption’ (Neilson 2003b));

8. multiple pregnancy (see review ’Caesarean delivery for the sec-ond twin’ (Crowther 1996));

9. suspected fetopelvic disproportion (see review ’Pelvimetry for fetal cephalic presentations at term’ (Pattinson 1997));

10. cord prolapse;

11. severe pre-eclampsia, HELLP syndrome or eclampsia; 12. maternal infections (e.g. HIV, active Herpes simplex) (see re-view ’Interventions for reducing the risk of mother-to-child trans-mission of HIV infection’ (Brocklehurst 2002));

13. mother’s choice (see ’Caesarean section for non-medical reasons at term’ (Lavender 2006) (Bèhague 2002;Efekhar 2000;Feldman 1985).

Less common indications include fetal coagulation defects (Silver 2000) and some fetal anomalies (How 2000;Luthy 1991). The emphasis of this review is on surgical techniques for caesarean section but, for completeness, aspects of anaesthesia and pre- and postoperative care will be covered briefly.

Preoperative preparation includes clinical assessment; blood tests such as haemoglobin, Rhesus group and antibody screen, testing for syphilis and HIV, and blood compatibility testing in high-risk cases (Cousins 1996;Ransom 1999); anaesthetic assessment; oral intake restriction when caesarean section is anticipated (see review ’Restricting oral fluids and food during labour’ (Singata 2002)); interventions to reduce the volume or acidity of stom-ach contents (Peskett 1973); intravenous fluids (avoiding exces-sive dextrose) (Kenepp 1982); antibiotic prophylaxis (see reviews ’Antibiotic prophylaxis for caesarean section’ (Smaill 2002), and ’Antibiotic prophylaxis regimens and drugs for caesarean section’ (Hopkins 1999)); and antiretroviral prophylaxis for HIV-positive

women not yet receiving antiretroviral therapy (see review ’An-tiretrovirals for reducing the risk of mother-to-child transmission of HIV infection’ (Volmink 2007)). A urinary catheter is inserted, and hair in the region of the proposed skin incision may be clipped. The question of prophylaxis against venous thromboembolism is dealt with in a separate review (’Prophylaxis for venous throm-boembolic disease in pregnancy and the early postnatal period’ ( Gates 2002)). In the operating theatre, the fetal lie, presentation and position are checked, and the presence of fetal heart beats confirmed. The indication for caesarean section is reviewed, as the obstetric situation may have changed since the original decision was made.

Preparedness includes the ability to arrange emergency caesarean sections within a limited time (e.g. 30 minutes) (ACOG 2001; James 2001), though the feasibility of this standard has been ques-tioned (MacKenzie 2001;Tufnell 2001).

Regional analgesia (spinal and epidural) has largely replaced gen-eral anaesthesia in many services. When other methods are not available or safe, local analgesic infiltration may be used (Hofmeyr 1995;Ranney 1975). Aspects of anaesthetic choice and technique are dealt with in other reviews (see protocol for review ’Spinal ver-sus epidural anaesthesia for caesarean section’ (Ng 2004); ’Tech-niques for preventing hypotension during spinal anaesthesia for caesarean section’ (Cyna 2006)).

Postoperative care includes regular checking of vital signs and urine output, and for signs of uterine relaxation and haemorrhage. Re-stricting oral intake has not been found to be of benefit (’Early compared with delayed oral fluids and food after caesarean sec-tion’ (Mangesi 2002)). Analgesia is provided (’Single dose oral ibuprofen and diclofenac for postoperative pain’ (Collins 1999); ’Single dose oxycodone and oxycodone plus paracetamol (ace-tominophen) for acute postoperative pain’ (Edwards 2000); ’Sin-gle dose paracetamol (acetaminophen), with and without codeine, for postoperative pain’ (Moore 1998)). Early mobility, skin-to-skin contact with the baby (Moore 2007) and breastfeeding are encouraged.

The major complications of caesarean section are intraoperative damage to organs such as the bladder or ureters (Nielsen 1984), anaesthetic complications, haemorrhage (Petitti 1985), infection ( Duff 1986;Owen 1994) and thromboembolism (Gherman 1999; Simpson 2001). Maternal mortality is greater after caesarean than vaginal delivery (Frigoletto 1980; Lilford 1990; Schuitemaker 1997), though it is difficult to be sure to what extent this is due to the operation or to the reason for the operation. Transient tachyp-noea of the newborn is more common after caesarean section, and birth trauma is not eliminated (Nielsen 1984). Long-term risks in-clude an increased risk of placenta praevia (Ananth 1997), placen-tal abruption (Lydon-Rochelle 2001a), placenta accreta (Clarke 1985) and uterine rupture (Lydon-Rochelle 2001b).

Over the years, many variations in the technique of caesarean 3 Techniques for caesarean section (Review)

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section have developed. Some aspects of the technique are dealt with in separate reviews.

1. The woman’s position may be supine or with a lateral tilt (’Lat-eral tilt for caesarean section’ (Wilkinson 2006a)).

2. The skin incision may be vertical (midline or paramedian) or transverse lower abdominal (Pfannenstiel, Joel-Cohen, Pelosi, Maylard, Mouchel or Cherney). For very obese women, a trans-verse incision above the umbilicus has been suggested, but not shown to decrease morbidity (Houston 2000). Electrocautery has been compared with cold knife incision for the abdominal wall opening (Meyer 1998). The lower leaf of the rectus sheath may be freed or not (Oguz 1998). A Cochrane review on abdominal surgical incisions for caesarean section is available (Mathai 2007). 3. The bladder peritoneum may be reflected downward or not ( Hohlagschwandtn 2001).

4. The uterine incision may be transverse lower segment (Munro-Kerr), midline lower segment or midline upper segment (’classi-cal’).

5. The uterus may be opened with a scalpel, scissors, by blunt dis-section, or using absorbable staples (’Absorbable staples for uterine incision at caesarean section’ (Wilkinson 2006b)).

6. The placenta may be removed manually or with cord traction, and allowing the cord to bleed has been used to assist placen-tal delivery (’Manual removal of placenta at caesarean section’ ( Wilkinson 2006c)).

7. The uterus may be delivered from the abdominal cavity or left in position during repair (’Extra-abdominal versus intra-abdominal repair of the uterine incision at caesarean section’ (Jacobs-Jokhan 2004)).

8. The uterus may be closed with interrupted or continuous su-tures in one, two or three layers (’Methods of closing the uterine incision at caesarean section’/’Single versus two layer suturing for closing the uterine incision at caesarean section’ (Enkin 2006). Observational studies have suggested that a single-layer closure is associated with more ultrasound scar defects (Hayakawa 2006) and is more likely to dehisce in subsequent pregnancies (Bujold 2002;Gyamfi 2006;Hamilton 2001). In another study, increased uterine ’windows’ were found following single-layer closure, but no scar ruptures occurred (Durnwald 2003).

9. Blood may be recovered during the procedure for re-transfusion (Rainaldi 1998).

10. The visceral or the parietal peritoneum, or both, may be su-tured or left unsusu-tured (’Peritoneal non-closure at caesarean sec-tion’ (Bamigboye 2003)).

11. Various materials may be used for closure of the fascia. In women at increased risk for wound dehiscence, a running Smead-Jones suture has been suggested (Wallace 1980).

12. Careful handling of tissues and good surgical technique are suggested to reduce the risk of infection (Iffy 1979;Lyon 1987). 13. The subcutaneous tissues may be sutured or not (Naumann 1995).

14. Various techniques and materials may be used for skin closure (’Techniques and materials for skin closure in caesarean section’ ( Alderdice 2003)).

Apart from variations in individual aspects of the operation as outlined above, several complete techniques of caesarean section have been described. Comparisons of such complete techniques will be evaluated in this review. Described techniques include the following.

1. The Pfannenstiel caesarean section

A Pfannenstiel abdominal incision is used. The skin and rectus sheath are opened transversely using sharp dissection. The rec-tus sheath is dissected free from the underlying recrec-tus abdomi-nus muscles. The peritoneum is opened longitudinally using sharp dissection. The uterus is opened with a transverse lower segment hysterotomy. The uterine incision is closed with two layers of con-tinuous sutures. Both peritoneal layers are closed with concon-tinuous sutures. The fascia is closed with continuous or interrupted su-tures. The skin is closed with interrupted or a continuous intra-cutaneous suture.

2. The Pelosi-type caesarean section (Capeless 2002; Wood 1999)

A Pfannenstiel abdominal incision is used. Electrocautery is used to divide the subcutaneous tissues and the fascia transversely. The rectus muscles are separated by blunt dissection to provide space for both index fingers, which free the fascial vertically and trans-versely. The peritoneum is opened by blunt finger dissection and all the layers of the abdominal wall are stretched manually to the extent of the skin incision. The bladder is not reflected inferi-orly. A small transverse lower segment incision is made through the myometrium, and extended laterally, curving upwards, with blunt finger dissection or scissors. The baby is delivered with exter-nal fundal pressure, oxytocin is administered and the placenta re-moved after spontaneous separation. The uterus is massaged. The myometrial incision is closed with a single-layer 0 chromic catgut continuous locking suture. Neither peritoneal layer is sutured. The fascia is closed with a continuous synthetic absorbable suture. If the subcutaneous layer is thick, interrupted 3-0 absorbable sutures are used to obliterate the dead space. The skin is closed with sta-ples.

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3. The Joel-Cohen technique

This differs from the above technique in several respects. The ’Joel-Cohen’ abdominal incision is used. This is a straight transverse incision through skin only, 3 cm below the level of the anterior superior iliac spines (higher than the Pfannenstiel incision). The subcutaneous tissues are opened only in the middle 3 cm. The fascia is incised transversely in the midline then extended laterally with blunt finger dissection (Joel-Cohen 1977;Wallin 1999). Fin-ger dissection is used to separate the rectus muscles vertically and laterally and open the peritoneum. All the layers of the abdominal wall are stretched manually to the extent of the skin incision. The bladder is reflected inferiorly. The myometrium is incised trans-versely in the midline but not to breach the amniotic sac, then opened and extended laterally with finger dissection. Interrupted sutures are used for the closure of the myometrium. Retrospective studies have suggested that these methods reduce operating time, blood loss and postoperative hospital stay (Song 2006). Various modifications of the Joel-Cohen technique have been described ( Franchi 1998;Ferrari 2001;Stark 1995;Wallin 1999).

4. The Misgav-Ladach technique (Holmgren 1999)

This is a modification of the Joel-Cohen technique, developed by Stark and colleagues (Stark 1995). The Joel-Cohen abdominal in-cision is used (see above), except that the fascia is opened with a blind thrusting movement of the slightly open scissor-tips. The uterus is opened as for the Joel-Cohen method (above). The pla-centa is removed manually. The uterus is exteriorized. The my-ometrial incision is closed with a single-layer locking continuous suture. The peritoneal layers are not sutured. The fascia is sutured with a continuous suture. The skin is closed with two or three mattress sutures. Between these sutures, the skin edges are approx-imated with Allis forceps, which are left in place for about five minutes while the drapes are being removed. The reported advan-tages include shorter operating time (Darj 1999;Franchi 1998; Mathai 2002;Wallin 1999), less use of suture material (Bjorklund 2000), less intraoperative blood loss (Bjorklund 2000;Darj 1999; Wallin 1999) less postoperative pain (Darj 1999;Mathai 2002) less wound infection (Franchi 1998), and fewer adhesions at re-peat surgery (Stark 1995). A retrospective comparison found that the classical Joel-Cohen incision was associated with statistically less postoperative blood collection in the abdominal wall, pouch of Douglas and lower uterine segment than the modified incision, but the differences were small (Malvasi 2007).

5. The extraperitoneal caesarean section

Historically the extraperitoneal approach was used in septic cases in an attempt to limit the spread of sepsis prior to the advent of effective antibiotics (Haesslein 1980). It is seldom used today.

O B J E C T I V E S

1. To compare, using the best available evidence, the effects of complete methods of caesarean section not covered in the reviews of individual aspects of caesarean section technique.

2. To summarise the findings of reviews of individual as-pects of caesarean section technique.

3. This will provide a holistic review of techniques of cae-sarean section with ready cross-reference to the detailed individual aspect reviews.

M E T H O D S

Criteria for considering studies for this review

Types of studies

We considered all published, unpublished and ongoing ran-domised controlled trials comparing intention to perform cae-sarean section by different techniques, excluding individual as-pects covered in other Cochrane reviews. We excluded quasi-ran-domised trials (e.g., those ranquasi-ran-domised by date of birth or hospital number) from the analysis unless there was a specific stated reason for inclusion. Studies reported only in abstract form with inade-quate methodological information were included in the ’Studies awaiting assessment’ category, to be included in the analyses when published as full reports, or adequate information was obtained from the authors. Studies were included if there was adequate allo-cation concealment and violations of allocated management and exclusions after allocation were not sufficient to materially affect outcomes.

Types of participants

Pregnant women due for delivery by elective or emergency cae-sarean section.

Types of interventions

Caesarean section performed according to a prespecified tech-nique, not covered by other reviews of individual aspects of cae-sarean section technique.

Types of outcome measures

Primary outcomes

(1) Serious intraoperative and postoperative complications, in-cluding organ damage, blood transfusion, significant sepsis, 5 Techniques for caesarean section (Review)

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thromboembolism, organ failure, high care unit admission or death;

(2) blood loss (as defined by trial authors); (3) blood transfusion.

Secondary outcomes

Short-term outcome measures for the woman

(4) Operating time; (5) maternal death;

(6) admission to intensive care unit;

(7) postoperative haemoglobin or haematocrit level, or change in these;

(8) postoperative anaemia, as defined by trial authors; (9) wound infection, as defined by trial authors; (10) wound haematoma;

(11) wound breakdown;

(12) endometritis, as defined by trial authors; (13) time to mobilisation;

(14) time to oral intake;

(15) time to return of bowel function; (16) time to breastfeeding initiation;

(17) fever treated with antibiotics or as defined by trialists; (18) repeat operative procedures carried out on the wound; (19) postoperative pain as measured by trial authors; (20) use of analgesia, as defined by trial authors;

(21) unsuccessful breastfeeding (at discharge or as defined by the trial authors);

(22) mother not satisfied with care.

Short-term outcome measures for the infant

(23) Time from anaesthesia to delivery; (24) time from skin incision to delivery; (25) birth trauma;

(26) cord blood pH less than 7.2;

(27) cord blood base deficit greater than 15; (28) Apgar score less than seven at five minutes; (29) neonatal intensive care admission; (30) encephalopathy;

(31) neonatal or perinatal death.

Longer-term outcomes for the mother

(32) Long-term wound complications e.g. numbness, keloid for-mation, incisional hernia;

(33) long-term abdominal pain; (34) future fertility problems;

(35) complications in future pregnancy (e.g. uterine rupture, pla-centa praevia, plapla-centa accreta);

(36) complications at future surgery (e.g. adhesion formation).

Health service use

(37) Length of postoperative hospital stay for mother or baby; (38) readmission to hospital of mother or baby, or both; (39) costs.

Outcomes were included if clinically meaningful; reasonable mea-sures taken to minimise observer bias; missing data insufficient to materially influence conclusions; data available for analysis ac-cording to original allocation, irrespective of protocol violations; data available in a format suitable for analysis.

Search methods for identification of studies

Electronic searches

We searched the Cochrane Pregnancy and Childbirth Group’s Tri-als Register by contacting the TriTri-als Search Co-ordinator (August 2007).

The Cochrane Pregnancy and Childbirth Group’s Trials Register is maintained by the Trials Search Co-ordinator and contains trials identified from:

1. quarterly searches of the Cochrane Central Register of Controlled Trials (CENTRAL);

2. monthly searches of MEDLINE;

3. handsearches of 30 journals and the proceedings of ma-jor conferences;

4. weekly current awareness search of a further 36 journals plus monthly BioMed Central email alerts.

Details of the search strategies for CENTRAL and MEDLINE, the list of handsearched journals and conference proceedings, and the list of journals reviewed via the current awareness service can be found in the ’Search strategies for identification of studies’ section within the editorial information about the Cochrane Pregnancy and Childbirth Group.

Trials identified through the searching activities described above are given a code (or codes) depending on the topic. The codes are linked to review topics. The Trials Search Co-ordinator searches the register for each review using these codes rather than keywords. In addition, we searched the Cochrane Central Register of Con-trolled Trials (The Cochrane Library 2007, Issue 3) using the search terms ’(caesarean OR cesarean) AND technique’ and conducted a manual search of the reference lists of all identified papers. We did not apply any language restrictions.

Data collection and analysis

1. Review of techniques of caesarean section

Trials under consideration were evaluated for appropriateness for inclusion and methodological quality without consideration of their results. This was done by two review authors according to the prestated eligibility criteria.

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Trials that met the eligibility criteria were assessed for quality using the following criteria:

1. generation of random allocation sequence: A = adequate, B = inadequate, C = unclear;

2. allocation concealment: A = adequate, B = inadequate, C = unclear;

3. blinding of participants: A = yes, B = inadequate, C = no, D = no information;

4. blinding of caregivers: A = yes, B = inadequate, C = no, D = no information;

5. blinding of outcome assessment: A = yes, B = inadequate, C = no, D = no information;

6. compliance with allocated intervention: A = less than 3% non-compliance, B = 3% to 9.9% non-non-compliance, C = 10% or more non-compliance, D = unclear;

7. completeness of follow-up data (including any differential loss of participants from each group): A = less than 3% of participants excluded, B = 3% to 9.9% of participants excluded, C = 10% to 19.9% excluded, D = 20% or more excluded, E = unclear; 8. analysis of participants in randomised groups: A = yes, B = inadequate, C = no, D = not clear.

If a publication did not report analysis of participants in their randomised groups, we attempted to restore them to the correct group (analysis by ’intention to treat’). If there was insufficient information in the report to allow this, we contacted the authors and requested further data.

Two authors extracted data from the original publications onto data extraction forms. We resolved differences of opinion by dis-cussion or referral to the primary editor. Data from different trials were combined if we considered them sufficiently similar for this to be reasonable. We performed meta-analyses using relative risks as the measure of effect size for binary outcomes, and weighted mean differences for continuous outcome measures. If trials used different ways of measuring the same continuous outcome (for example, pain), we used standardised mean differences. We used a fixed-effect meta-analysis for combining study data if the trials were judged to be sufficiently similar. We investigated heterogeneity by calculating I² statistics (Higgins 2002), and if this indicated a high level of heterogeneity among the trials in-cluded in an analysis (I² greater than 50%), we used a random-effects meta-analysis for an overall summary. Where high levels of heterogeneity were found, they were explored by the prespecified subgroup analyses and by sensitivity analyses excluding the trials most susceptible to bias, based on the quality assessment: those with inadequate allocation concealment (B or C); high levels of postrandomisation losses or exclusions (D); or unblinded outcome assessment, or blinding of outcome assessment uncertain. The following subgroup analyses were planned:

1. first versus repeat versus mixed or undefined caesarean section;

2. prelabour versus intrapartum versus mixed or undefined caesarean section;

3. preterm versus term versus mixed or undefined cae-sarean section.

Differences in the effect of the intervention between subgroups were to be investigated as described byDeeks 2001(subject to sufficient numbers of trials).

2. Summary of other reviews of caesarean section techniques

Relevant reviews were summarised under the following headings. 1. Title

2. Review authors

3. Main results of the interventions, with numbers of trials and participants

4. Author’ implications for practice 5. Authors’ implications for research

A routine caesarean section technique based on best evidence was described, specifying options where no clear evidence for prefer-ence was found, and cross-referencing the relevant Cochrane re-views.

R E S U L T S

Description of studies

See:Characteristics of included studies;Characteristics of excluded studies.

We identified twenty-three studies which compared different tech-niques of caesarean section based on the search strategies. We ex-cluded four trials from the analyses as allocation to intervention groups was not based on randomisation in these trials (Ansaloni 2001;Gaucherand 2001;Redlich 2001;Wallace 2000). The de-tails of these studies can be found in the table of ’Characteristics of excluded studies’.

Five studies (Behrens 1997;Decavalas 1997;Direnzo 2001;Hagen 1999;Meyer 1998b) were presented at various meetings and con-ferences and contain only limited results of the studies. We have not obtained the more detailed information on the results of the above-mentioned trials from the authors.

There was some variation in the details of techniques defined by the authors as ’Joel-Cohen’, Misgav-Ladach’, and ’modified Mis-gav-Ladach’. All these methods have been based on the surgical principles developed by Joel-Cohen: blunt separation of tissues along natural tissue planes, using a minimum of sharp dissection. For the purposes of this review we have classified the methods as subgroups of the ’Joel-Cohen based’ techniques, as follows:

• ’Joel-Cohen’: Joel-Cohen abdominal and uterine entry; uterus closed with interrupted sutures; peritoneum not closed; skin closed with subcutaneous suture (Wallin 1999b).

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• ’Misgav-Ladach’: Joel-Cohen abdominal entry and uterine entry; uterus closed with single-layer locked continuous suture; peritoneum not closed; skin closed with widely spaced interrupted sutures (Bjorklund 2000;Dani 1998;Darj 1999;Ferrari 2001;Heimann 2000;Li 2001;Mathai 2002;Moreira 2002). • ’Modified Misgav-Ladach’: as above but either skin

closed with subcutaneous suture (Koettnitz 1999) or various skin closure methods (Xavier 2005) or uterus closed with single-layer non-locking continuous su-ture (Franchi 1998b; Franchi 2002); or visceral peri-toneum not opened and uterus closed with two non-locked suture layers (Li 2001); or the skin opened at the level of the Pfannenstiel incision for cosmetic reasons ( Heimann 2000).

Eleven studies have investigated the difference between Joel-Co-hen-based and Pfannenstiel caesarean section techniques (Dani 1998; Darj 1999;Ferrari 2001; Franchi 1998b; Franchi 2002; Heimann 2000;Koettnitz 1999;Li 2001;Mathai 2002;Wallin 1999b;Xavier 2005).

Two studies (Bjorklund 2000;Moreira 2002) compared the Mis-gav-Ladach technique with traditional (lower midline abdominal incision) caesarean sections.

One study compared extraperitoneal and intraperitoneal caesarean section techniques (Mokgokong 1974).

Details of the above-mentioned studies are available in the ’Char-acteristics of included studies’ table.

Risk of bias in included studies

The methodological quality of the included studies was variable. The allocation concealment was unclear in three studies (Dani 1998;Moreira 2002;Xavier 2005). Given the type of intervention, the surgical team was not blinded to the allocated intervention. The allocation was usually revealed just before the skin incision was made. Assessment of intraoperative variables (e.g. operating time, estimated blood loss) may have been subject to bias. However, the assessment of postoperative outcomes (e.g. febrile morbidity, pain, analgesic requirements) was blinded in the majority of studies. Refer to the table ’Characteristics of included studies’ for more details on the methodological quality of the individual studies. One study with inadequate allocation concealment and unex-plained differences in group numbers (Mokgokong 1974) was in-cluded for historical interest.

Effects of interventions

’Joel-Cohen based’ versus Pfannenstiel caesarean section (CS)

Eleven studies compared ’Joel-Cohen based’ and Pfannenstiel CS. These were subgrouped as follows: Joel-Cohen (Mathai 2002; Wallin 1999b); Misgav-Ladach (Dani 1998;Darj 1999;Ferrari 2001;Li 2001); and Modified Misgav-Ladach (Franchi 1998b; Franchi 2002;Heimann 2000;Koettnitz 1999;Li 2001;Xavier 2005).

Serious complications were reported in only four trials (913 women) in the modified Misgav-Ladach versus Pfannenstiel com-parisons, and were too few for meaningful statistical analysis (three and two events respectively).

Only three blood transfusions were reported, all in the modified Misgav-Ladach groups (three trials, 681 women).

’Joel-Cohen based’ surgery was associated with:

• less blood loss in all trials (five trials, 481 women; weighted mean difference (WMD) 64.45 ml; 95% con-fidence interval (CI) -91.34 to -37.56 ml).

• shorter operating time in all trials. There was signifi-cant heterogeneity in the magnitude of the reduction (I² = 93%). The overall WMD was a reduction of 18.65 minutes (five trials, 481 women; 95% CI 24.84 to -12.45 minutes; random-effects model).

• no overall difference in the occurrence of wound infec-tions (six trials, 1071 women, considerable heterogene-ity).

• no difference in postoperative haematocrit level and haemoglobin fall greater than 4 g%, reported in one trial each (Heimann 2000;Mathai 2002), (101 women and 240 women respectively).

• a trend to increased wound haematoma in the modi-fied Misgav-Ladach subgroup in one trial in which this outcome was reported (Heimann 2000; 240 women; relative risk (RR) 1.80; 95% CI 0.98 to 3.31). • no significant difference in wound breakdown (three

trials, 468 women).

• inadequate data on endometritis, reported in only one woman, in the Pfannenstiel group (three trials, 767 women).

• postoperatively, an overall reduction with significant heterogeneity (I² = 90%) in time to oral intake (five tri-als, 481 women; WMD -3.92; 95% CI -7.13 to -0.71 hours; random-effects model).

• no significant difference in time to return of bowel func-tion.

• no significant difference in time to mobilisation (two trials, 208 women; WMD -2.86; 95% CI -11.29 to 5.56) or in time to breastfeeding initiation (one trial, 101 women).

• less fever, treated with antibiotics or as defined by trial authors (eight trials, 1412 women; RR 0.47; 95% CI 0.28 to 0.81).

• insufficient data on repeat operative procedure on the wound, which were reported in only one woman, in the

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Pfannenstiel group (two trials, 228 women).

• lower duration of postoperative pain (two comparisons from one trial, 172 women; WMD -14.18 hours; 95% CI -18.31 to -10.04 hours) and less use of analgesia, defined as number of analgesic injections (Darj 1999) or number of injections in the first 24 hours (Mathai 2002) (two trials, 151 women; WMD 0.92; 95% CI -1.20 to -0.63).

• shorter time from skin incision to birth of the baby in all trials. There was significant heterogeneity in the magnitude of the reduction (I² = 89.5%). The overall WMD was a reduction of 3.84 minutes (five trials, 575 women; 95% CI -5.41 to -2.27 minutes; random-ef-fects model).

• insufficient data on low Apgar scores (two low scores in the Pfannenstiel group, one trial, 158 women). • No difference in neonatal intensive care admission (one

trial, 310 women).

Subgroup analyses

Four trials were reported to be limited to women undergoing ab-dominal surgery for the first time (Darj 1999;Ferrari 2001;Mathai 2002;Wallin 1999b). The results were similar to those for all the trials.

There were insufficient data to conduct further subgroup analyses.

Misgav-Ladach versus traditional (lower midline abdominal incision)

Only one of two trials contributed data for each outcome ( Bjorklund 2000;Moreira 2002).

The Misgav-Ladach method was associated with reduced blood loss (339 women; WMD -93.00; 95% CI -132.72 to -53.28 ml); operating time (339 women; WMD -7.30; 95% CI -8.32 to -6.28 minutes); time to mobilisation (339 women; WMD -16.06; 95% CI -18.22 to -13.90 hours); and length of postoperative stay for

the mother (339 women; WMD -0.82; 95% CI -1.08 to -0.56 days).

There were no significant differences in postoperative anaemia (339 women); wound infection (339 women); wound breakdown (339 women); endometritis (400 women); or fever (339 women).

Misgav-Ladach versus modified Misgav-Ladach methods

In one trial (Li 2001; 116 women), the Misgav-Ladach method was associated with a longer time from skin incision to birth of the baby (WMD 2.10; 95% CI 1.10 to 3.10 minutes), and no significant differences in blood loss, time to oral intake, time to return of bowel function, postoperative pain score, operating time, or length of postoperative stay of the mother.

Extraperitoneal versus intraperitoneal CS

One study with poor methodology by current standards compared extraperitoneal and intraperitoneal CS techniques (Mokgokong 1974). One woman out of 173 had serious complications during or after extraperitoneal CS in comparison to 12 women out of 239 in the group who had intraperitoneal CS (RR 0.12; 95% CI 0.02 to 0.88). The rate of maternal mortality did not differ between these two groups. The rate of fever treated with antibiotics was lower in the extraperitoneal CS group (RR 0.42; 95% CI 0.27 to 0.65). There was no significant difference in the numbers who had repeat procedures on the wound. The results should be interpreted with caution.

Subgroup analyses

There were insufficient trials which were limited to homogenous subgroups other than primary, prelabour and term CS for mean-ingful subgroup analyses.

Table 1shows a summary of Cochrane reviews on various aspects of CS techniques.

Table 1. Summary of Cochrane reviews on various aspects of caesarean section techniques

Review Main results Practice Research

Preoperative hair removal to re-duce surgical site infection. Tanner J, Woodlings D, Mon-caster K.

11 RCTs.

2 studies, 411 participants com-pared the Joel-Cohen incision with the Pfannenstiel incision.

No statistically significant dif-ference in surgical site infec-tions (SSI) was found compar-ing hair removal uscompar-ing either de-pilatory cream or razors with no hair removal (3 trials, 625 peo-ple). There were significantly more SSIs when people were

There is no evidence that hair removal prior to surgery re-duced SSI. If it is necessary to remove hair then both clipping and depilatory creams results in fewer SSIs than shaving using a razor. There is no difference in SSIs when patients are shaved or

No trials were found that com-pared clipping with a depilatory cream.

No trials were identified which compared clipping with no hair removal.

No trials were found that com-pared depilatory cream at

dif-9 Techniques for caesarean section (Review)

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Table 1. Summary of Cochrane reviews on various aspects of caesarean section techniques (Continued) shaved compared with either

clipping (3 trials, 3193 people; RR 2.02, 95%.CI 1.21 to 3.36) or hair removal using a depila-tory cream (7 trials, 1213 peo-ple; RR 1.54, 95%CI 1.05 to 2.24). No difference in SSIs was found between shaving (1 trial) or clipping (1 trial) on the day of surgery compared with the day before surgery.

clipped one day before surgery or on the day of surgery.

ferent times or that compared hair removal in different set-tings.

Preoperative bathing or shower-ing with skin antiseptics to pre-vent surgical site infection. Webster J, Osborne S. 6 trials, 10,007 participants.

The antiseptic used in all tri-als was 4% chlorhexidine glu-conate. In 3 trials involving 7691 participants bathing with chlorhexidine compared with a placebo did not result in a sta-tistically significant reduction in SSIs, (RR = 0.91 (95% CI 0.80 to 1.04). When only tri-als of high quality were in-cluded in this comparison, the RR of SSI was 0.95 (95% CI 0.82 to 1.10). 3 trials of 1443 participants compared bar soap with chlorhexidine; when com-bined there was no difference in the risk of SSIs (RR 1.02, 95% CI 0.57 to 1.84). 2 trials of 1092 patients com-pared bathing with chlorhexi-dine with no washing, 1 large study found a statistically sig-nificant difference in favour of bathing with chlorhexidine (RR 0.36, 95% CI 0.17 to 0.79). The second smaller study found no difference between patients who washed with chlorhexidine and those who did not wash preoperatively.

This review provides no clear evidence of benefit for preoper-ative showering or bathing with chlorhexidine over other wash products, to reduce surgical site infection.

More research is needed in this area.

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Table 1. Summary of Cochrane reviews on various aspects of caesarean section techniques (Continued)

Double gloving to reduce surgi-cal cross-infection.

Tanner J, Parkinson H. 2 trials on surgical site infec-tions.

31 RCTs on glove perforations.

2 trials were found which ad-dressed the primary outcome, namely, surgical site infections in patients. Both trials reported no infections.

14 trials of double gloving (wearing 2 pairs of surgical la-tex gloves) were pooled and showed that there were signifi-cantly more perforations to the single glove than the innermost of the double gloves (OR 4.10, 95% CI 3.30 to 5.09). 8 trials of indicator gloves (coloured latex gloves worn un-derneath latex gloves to more rapidly alert the team to per-forations) showed that signifi-cantly fewer perforations were detected with single gloves compared with indicator gloves (OR 0.10, 95% CI 0.06 to 0.16) or with standard double glove compared with indicator gloves (OR 0.08, 95% CI 0.04 to 0.17).

2 trials of glove liners (a glove knitted with cloth or poly-mers worn between 2 pairs of latex gloves)(OR 26.36, 95% CI 7.91 to 87.82), 3 trials of knitted gloves (knitted glove worn on top of latex surgical gloves)(OR 5.76, 95% CI 3.25 to 10.20) and 1 trial of triple gloving (3 pairs of latex surgi-cal gloves)(OR 69.41, 95% CI 3.89 to 1239.18) all compared with standard double gloves, showed there were significantly more perforations to the inner-most glove of a standard double glove in all comparisons.

There is no direct evidence that additional glove protection worn by the surgical team re-duces surgical site infections in patients, however the review has insufficient power for this out-come.

The addition of a second pair of surgical gloves, triple gloving, knitted outer gloves and glove liners all significantly reduce perforations to the innermost glove. Perforation indicator sys-tems results in significantly more innermost glove perfo-rations being detected during surgery.

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Disposable surgical face masks for preventing surgical wound infection in clean surgery. Lipp A, Edwards P. 2 RCTs, 1453 participants.

In 1 small trial there was a trend towards masks being associated with fewer infections, whereas in 1 large trial there was no sta-tistically significant difference in infection rates between the masked and unmasked group.

From the limited results it is un-clear whether wearing surgical face masks results in any harm or benefit to the patient under-going clean surgery.

Further research is required.

Antibiotic prophylaxis for ce-sarean section.

F Smaill, GJ Hofmeyr. 81 trials.

Use of prophylactic antibiotics in women undergoing cae-sarean section substantially re-duced the incidence of episodes of fever, endometritis, wound infection, urinary tract infec-tion and serious infecinfec-tion after caesarean section. The reduc-tion in the risk of endometri-tis with antibiotics was similar across different patient groups: RR for endometritis for elective caesarean section (number of women = 2037) was 0.38 (95% CI 0.22 to 0.64); the RR for non-elective caesarean section (n = 2132) was 0.39 (95% CI 0.34 to 0.46); and the RR for all patients (n = 11,937) was 0.39 (95% CI 0.31 to 0.43). Wound infections were also reduced: for elective caesarean section (n = 2015) RR 0.73 (95% CI 0.53 to 0.99); for non-elective cae-sarean section (n = 2780) RR 0.36, 95% CI 0.26 to 0.51]; and for all patients (n = 11,142) RR 0.41 (95% CI 0.29 to 0.43).

The reduction of endometritis by two thirds to three quarters and a decrease in wound infec-tions justifies a policy of rec-ommending prophylactic an-tibiotics to women undergo-ing elective or non-elective cae-sarean section.

Antibiotic

prophylaxis regimens and drugs for cesarean section.

L Hopkins, F Smaill. 51 trials.

The following results refer to re-ductions in the incidence of en-dometritis. Both ampicillin and first-generation cephalosporins have similar efficacy with an

Both ampicillin and first gener-ation cephalosporins have sim-ilar efficacy in reducing post-operative endometritis. There does not appear to be added

There is a need for an appropri-ately designed randomised trial to test the optimal timing of ad-ministration (immediately after

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Table 1. Summary of Cochrane reviews on various aspects of caesarean section techniques (Continued) odds ratio (OR) of 1.27 (95%

CI: 0.84 to 1.93). In comparing ampicillin with second or third-generation cephalosporins the OR was 0.83 (95% CI 0.54 to 1.26) and in comparing a first-generation cephalosporin with a second or third-generation agent the OR was 1.21 (95% CI 0.97-1.51). A multiple dose regimen for prophylaxis appears to offer no added benefit over a single dose regimen; OR 0.92 (95% CI 0.70 to 1.23). Sys-temic and lavage routes of ad-ministration appear to have no difference in effect; OR 1.19 (95% CI 0.81 to 1.73).

benefit in utilizing a more broad spectrum agent or a multiple dose regimen.

the cord is clamped versus pre-operative).

Regional versus general anaes-thesia for caesarean section. BB Afolabi, FEA Lesi, NA Merah. 16 trials, 1586 women.

Women who had either epidu-ral anaesthesia or spinal anaes-thesia were found to have a sig-nificantly lower difference be-tween pre and postoperative haematocrit (WMD 1.70, 95% CI 0.47 to 2.93, 1 trial, 231 women) and (WMD 3.10, 95% CI 1.73 to 4.47, 1 trial, 209 women). Compared to GA, women having either an epidu-ral anaesthesia or spinal had a lower estimated maternal blood loss (WMD - 126.98 millilitres, 95% CI 225.06 to -28.90, 2 trials, 256 women) and (WMD -84.79 millilitres, 95% CI -126.96 to -42.63, 2 tri-als, 279 women). More women preferred to have GA for sub-sequent procedures when com-pared with epidural (OR 0.56, 95% CI 0.32 to 0.96, 1 trial, 223 women) or spinal (OR 0.44, 95% CI 0.24 to 0.81, 221 women). The incidence of

nau-There is not enough evidence from this review to show that either regional or general anaes-thesia is superior to the other in terms of major maternal or neonatal outcomes. Thus, the choice of one over the other lies with other criteria such as es-timated blood loss which ap-pears to be reduced with the use of regional anaesthesia, and client satisfaction and nausea and vomiting which appear to be reduced with general anaes-thesia.

Further research to evaluate neonatal morbidity and mater-nal outcomes, such as satisfac-tion with technique, will be use-ful.

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Table 1. Summary of Cochrane reviews on various aspects of caesarean section techniques (Continued) sea was also less for this group of

women compared with epidu-ral (OR 3.17, 95% CI 1.64 to 6.14, 3 trials, 286 women) or spinal (OR 23.22, 95% CI 8.69 to 62.03, 209 women). No significant difference was seen in terms of neonatal Apgar scores of 6 or less and of 4 or less at 1 and 5 minutes and need for neonatal resuscitation with oxygen.

Spinal versus epidural anaesthe-sia for caesarean section. K Ng, J Parsons, AM Cyna, P Middleton.

10 trials, 751 women.

No difference was found be-tween spinal and epidural tech-niques with regards to failure rate (RR 0.98, 95% CI 0.23 to 4.24; 4 studies), need for ad-ditional intraoperative analge-sia (RR 0.88, 95% CI 0.59 to 1.32; 5 studies), need for con-version to general anaesthesia intraoperatively, maternal sat-isfaction, need for postopera-tive pain relief and neonatal intervention. Women receiving spinal anaesthesia for caesarean section showed reduced time from start of the anaesthetic to start of the operation (WMD 7.91 minutes less (95% CI -11.59 to -4.23; 4 studies), but increased need for treatment of hypotension RR 1.23 (95% CI 1.00 to 1.51; 6 studies).

Both spinal and epidural tech-niques are shown to provide ef-fective anaesthesia for caesarean section. Both techniques are associated with moderate de-grees of maternal satisfaction. Spinal anaesthesia has a shorter onset time, but treatment for hypotension is more likely if spinal anaesthesia is used. No conclusions can be drawn about intraoperative side-ef-fects and postoperative compli-cations because they were of low incidence or not reported, or both.

More research is needed on intraoperative side-effects and postoperative complications of spinal and epidural anaesthesia.

Abdominal surgical incisions for caesarean section.

M Mathai, GJ Hofmeyr. 2 studies, 411 participants com-pared the Joel-Cohen incision with the Pfannenstiel incision.

65% reduction in reported postoperative morbidity with the Joel-Cohen incision. 1 of the trials reported reduced postoperative analgesic require-ments; operating time; deliv-ery time; total dose of analgesia in the first 24 hours; estimated

The Joel-Cohen incision has clinical and cost-saving bene-fits.

Opinions of women and care-givers, severe immediate mor-bidity or long-term mormor-bidity and mortality among mothers and infants were not evaluated. There is a also need to study if these procedures can be done safely under local anaesthesia in

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Table 1. Summary of Cochrane reviews on various aspects of caesarean section techniques (Continued) blood loss; postoperative

hospi-tal stay for the mother; and in-creased time to the first dose of analgesia compared to the Pfan-nenstiel group. No other signif-icant differences were found in either trial.

2 studies compared muscle cutting incisions with Pfan-nenstiel incision. 1 study (68 women) comparing Mouchel incision with Pfannenstiel in-cision did not contribute data to this review. The other study (97 participants) comparing the Maylard muscle-cutting inci-sion with the Pfannenstiel in-cision, reported no difference in febrile morbidity; need for blood transfusion; wound in-fection; physical tests on muscle strength at 3 months postoper-ative and postoperpostoper-ative hospital stay.

settings where safe general or re-gional anaesthesia is not avail-able.

Tocolysis for assisting delivery at caesarean section.

JM Dodd, K Reid. 1 RCT, 97 women.

Maternal and infant health out-comes were not reported.

There is currently insufficient information available from ran-domised trials to support or re-fute the routine or selective use of tocolytic agents to facilitate infant birth at the time of cae-sarean section.

Research is needed in this area.

Closure versus non-closure of the peritoneum at caesarean section.

AA Bamigboye, GJ Hofmeyr. Interventions - comparison of leaving the visceral or parietal peritoneum, or both, unsutured at caesarean section with a tech-nique which involves suturing the peritoneum.

14 trials, 2908 women.

Non-closure of the peritoneum reduced operating time whether both or either layer was not su-tured. For both layers, the op-erating time was reduced by 6.05 minutes. There was signif-icantly less postoperative fever and reduced postoperative stay in hospital and reduced number of postoperative analgesic doses

Leaving the peritoneum unsu-tured is not likely to be haz-ardous in the short term and may in fact, be of benefit. The long-term implications are not certain.

Further research on the long-term benefits or complications of non-closure of the peri-toneum at caesarean section is needed.

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Table 1. Summary of Cochrane reviews on various aspects of caesarean section techniques (Continued) for visceral peritoneum and for

both layer non-closure.

Techniques and materials for closure of the abdominal wall in caesarean section.

ER Anderson, S Gates.

The risk of haematoma or seroma was reduced with fat closure compared with non-clo-sure (RR) 0.52, 95% CI 0.33 to 0.82), as was the risk of ’wound complication’ (RR 0.68, 95% CI 0.52 to 0.88). No difference in the risk of wound infection alone or other short-term out-comes was found. No long-term outcomes were reported. There was no difference in the risk of wound infection between blunt needles and sharp needles in 1 small study. No studies were found examining suture tech-niques or materials for closure of the rectus sheath or subcuta-neous fat.

Closure of the subcutaneous fat may reduce wound complica-tions but it is unclear to what ex-tent these differences affect the wellbeing and satisfaction of the women concerned.

Further trials are justified to investigate whether the appar-ent increased risk of haematoma or seroma with non-closure of the subcutaneous fat is real. These should use a broader range of short- and long-term outcomes, and ensure that they are adequately powered to de-tect clinically important differ-ences. Further research compar-ing blunt and sharp needles is justified, as are trials evaluating suturing materials and suturing techniques for the rectus sheath.

Techniques and materials for skin closure in caesarean sec-tion.

F Alderdice, D McKenna, J Dornan.

Interventions - comparison of the effects of skin closure tech-niques and materials on mater-nal outcomes and time taken to perform a caesarean section. 1 RCT, 66 women.

While operating time was sig-nificantly shorter when using staples, the use of absorbable subcuticular suture resulted in less postoperative pain and yielded a better cosmetic result at the postoperative visit.

There is currently no conclu-sive evidence about how the skin should be closed after cae-sarean section. The choice of technique and materials should be made by women in con-sultation with their obstetrician based on the limited informa-tion currently available.

Future studies should concen-trate on minimizing scarring and infection and long-term maternal morbidity and scar ap-pearance as well as an ability of scar to withstand rupture in fu-ture pregnancies.

Techniques for caesarean sec-tion.

GJ Hofmeyr, M Mathai, A Shah, N Novikova.

Comparison of the effects of complete methods of caesarean section not covered in the re-views of individual aspects of caesarean section technique. To summarise the findings of

re-Shorter operating time, time to mobilisation, postoperative hospital stay and less blood loss in Misgav-Ladach group in comparison to traditional (lower midline) CS.

Comparison of Misgav-Ladach and Pfannenstiel techniques for CS revealed advantages of the former technique in relation to such outcomes as time from

Available evidence suggests that Misgav-Ladach, modified Mis-gav-Ladach and Joel-Cohen CS techniques have advantages over Pfannenstiel and tradi-tional (lower midline) CS tech-niques in relation to short-term outcomes. There is no evidence in relation to long-term out-comes.

Further research of the long-term outcomes after different CS techniques is needed. The study of women and caregivers satisfaction with surgery as well as healthcare facilities use will be useful. None of the studies compared Joel-Cohen and Mis-gav-Ladach CS techniques.

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Table 1. Summary of Cochrane reviews on various aspects of caesarean section techniques (Continued) views of individual aspects of

caesarean section technique. 14 studies, 2929 women.

skin incision to delivery of baby, blood loss, postoperative pain score, time to oral intake.

Joel-Cohen CS technique was found to have advantages in compar-ison to Pfannenstiel technique, e.g. shorter operating time, less significant blood loss, shorter time to oral intake was shorter, shorter time from skin incision to delivery, shorter time to mo-bilization, less use of analgesia, shorter length of postoperative mothers hospital stay. 6 trials, which included 1026 women, significantly decreased number of cases of fever treated with an-tibiotics.

The advantages of modified Misgav-Ladach technique over Pfannenstiel technique were seen in shorter operating time, shorter time from skin incision to delivery of baby, shorter time to oral intake, shorter time to return of bowel function, and less postoperative pain. The only advantage of modified Misgav-Ladach technique over Misgav-Ladach technique was shorter time from skin incision to delivery of baby.

Extraperitoneal CS in women with severe intrauterine sepsis had less number of serious com-plications in comparison to in-traperitoneal technique. Other outcomes that favoured ex-traperitoneal CS were the rate of fever treated with antibiotics. More women in a group, which had extraperitoneal CS, had re-peat procedures on the wound in comparison to these who had intraperitoneal CS.

Extraperitoneal CS has advan-tages over intraperitoneal CS in septic women in relation to serious maternal mortality and febrile morbidity.

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Wound drainage for CS. Gates S, Anderson ER. 7 trials (1993 women).

No difference in the risk of wound infection, other wound complications, febrile morbid-ity or endometritis in women who had wound drains com-pared with those who did not. There was some evidence that caesarean sections may be about 5 minutes shorter and that blood loss may be slightly lower when drains were not used.

There is no evidence in the 7 small trials included to suggest that the routine use of wound drains at CS confers any benefit on the women involved. These trials do not answer the question of whether wound drainage is of benefit when haemostasis is not felt to be ad-equate.

Further large trials are justified to examine the role of differ-ent types of wound drain at CS, comparing the use of drains in women with different de-grees of obesity and in women having first or repeat CS and intrapartum or prelabour CS, women’s views and experience of drains.

Tissue adhesives for closure of surgical incision.

Couthard P, Worthington H, Esopsito M, van der Elst M, van Waes OJF.

8 RCT, 630 patients.

No differences were found be-tween various tissue adhesives and sutures (8 trials) for de-hiscence, infection, satisfaction with cosmetic appearance when assessed by patients’ or sur-geons’ general satisfaction. Nor were differences found between a tissue adhesive and tapes (2 trials) for infection, patients’ as-sessment of cosmetic appear-ance, patient satisfaction or sur-geon satisfaction.

A statistically significant differ-ence was found for surgeons’ assessment of cosmetic appear-ance with mean difference 13 (95% CI 5 to 21), the higher mean rating for the tissue adhe-sive group.

Surgeons may consider the use of tissue adhesives as an alterna-tive to sutures or adhesive tape for the closure of incisions in the operating room.

There is a need for trials in all areas but in particular to clude patients that require in-cision closure in areas of high tension and patients of general health that may impair wound healing.

Removal of nail polish and fger rings to prevent surgical in-fection.

Arrowsmith VA, Maunder JA, Sargent RJ, Taylor R.

No RCTs that compared the wearing of finger rings with the removal of finger rings. No trials of nail polish wear-ing/removal that measured pa-tient outcomes, including sur-gical infection.

1 small RCT, which evaluated the effect of nail polish on the number of bacterial colony forming units on the hands af-ter preoperative hand washing

Not enough evidence about whether people working in op-erating theatres can wear nail polish or rings on their fingers without increasing patients’ in-fection rates.

Trials in this area are required.

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Table 1. Summary of Cochrane reviews on various aspects of caesarean section techniques (Continued) (also called surgical scrubbing).

Nurses were allocated to: un-polished nails, freshly applied nail polish (less than 2 days old), or old nail polish (more than 4 days old). Both before and after surgical scrubbing, there was no significant difference in the number of bacteria on the hands.

Preoperative skin antiseptics for preventing surgical wound in-fections after clean surgery. Edwards PS, Lipp A, Holmes A.

3 RCTs.

There was significant hetero-geneity in the comparisons and the results could not be pooled. In 1 study, infection rates were significantly lower when skin was prepared using chlorhex-idine compared with iodine. There was no evidence of a ben-efit in 4 trials associated with the use of iodophor impregnated drapes.

There is insufficient research ex-amining the effects of preoper-ative skin antiseptics to allow conclusions to be drawn regard-ing their effects on postopera-tive surgical wound infections.

Further research is needed.

Early compared with delayed oral fluids and food after cae-sarean section.

L Mangesi, GJ Hofmeyr. 6 RCTs.

Early oral fluids or food were as-sociated with: reduced time to first food intake (1 study, 118 women; the intervention was a slush diet and food was intro-duced according to clinical pa-rameters; WMD - 7.20 hours, 95% CI -13.26 to -1.14); re-duced time to return of bowel sounds (1 study, 118 women; -4.30 hours, -6.78 to -1.82); reduced postoperative hospital stay following surgery under re-gional analgesia (2 studies, 220 women; 0.75 days, 1.37 to -0.12 - random-effects model); and a trend to reduced abdom-inal distension (3 studies, 369 women; RR 0.78, 95% CI 0.55 to 1.11). No significant differ-ences were identified with re-spect to nausea, vomiting, time

There was no evidence from the limited randomised trials re-viewed, to justify a policy of withholding oral fluids after un-complicated CS.

Further research is justified.